Mental health special feature: the big issues

From vulnerable women on mixed-sex wards to continued over-representation of BME groups, Mental Health Act Commission chief executive Chris Heginbotham has a lot on his plate. Emma Dent reports

'Unacceptable' is a word Mental Health Act Commission chief executive Chris Heginbotham uses a lot when describing standards in inpatient mental healthcare. That he feels the need to do so is an indication of the number of issues warranting attention.

The commission's status as monitor of the use of the Mental Health Act and co-ordinator of the annual Count Me In census of inpatients means he is ideally placed to comment.

The 2006 Count Me In and its predecessor give a revealing insight into inpatient care. A survey of all psychiatric inpatients on a given day, it showed wards often running at unsustainable levels of occupancy, with many at over 100 per cent.

Service users are now unlikely to be inpatients unless extremely ill. A bad atmosphere and insufficient staff numbers can create uncomfortable places for patients to live in.

But, shockingly, inpatient wards are frequently going beyond being non-therapeutic to being downright dangerous. 'We know from the 2006 National Patient Safety Agency report that on average one female patient a month is raped on inpatient wards in this country,' says Mr Heginbotham. 'We simply cannot accept this.'

Although single-sex facilities are increasingly provided, some areas are still shared or the single-sex areas can only be accessed via mixed-sex areas. Bed pressures are still leading to women being admitted to male-only environments. 'The commission recently ran a notification process asking services to tell us when they placed a woman as the only woman on male wards and we had a substantial number of them,' says Mr Heginbotham.

'It must be frightening to be on a ward where people are likely to be disorderly and violent. And these are places where we are supposed to be helping people. It beggars belief.'

Mr Heginbotham wants more accountability for patient abuse. 'We need to truly hold chief executives and senior management to account so that perhaps their job is dependent on it,' he says. He admits, however, that lack of resources can make this more difficult to achieve.

'Improvements are not going to happen without resources. There are not enough staff in some services and some just do not have the scope to cope with some of the abuses.'

High vacancies and agency staff levels continue to exacerbate. In such circumstances it becomes very difficult for managers to have effective team working,' says Mr Heginbotham. 'We have to recognise how tough these jobs are. We should pay more for those working in such positions and demand a higher level of engagement with the patients.'

The profile of service users raises its own areas of alarm. Count Me In was set up as part of Delivering Race Equality, the government response to an independent inquiry into the death of a young black mental health patient David 'Rocky' Bennett in 1998 and concerns regarding over-representation of certain ethnic groups in inpatient care. Commission chair Kamlesh Patel has called for a public inquiry into what Mr Heginbotham calls 'one of the most pressing public health scandals of the modern health service'.

'Count Me In highlighted the much higher likelihood that you would be admitted if you were from black African, black Caribbean and so-called black other, which is essentially black British. Men from that group are 18 times more likely to be admitted to a psychiatric hospital,' says Mr Heginbotham.

Former junior health minister Rosie Winterton wrote to strategic health authorities warning them that black and minority ethnic service users were being discriminated against.

But Mr Heginbotham believes many feel the Department of Health did not take a tough enough approach. 'There is disappointment that the government did not recognise institutional racism in the NHS as a factor [in the inquiry into the death of Rocky Bennett] and did not move more swiftly to try and do something about it,' he says.

Mr Heginbotham adds: 'There is clearly evidence that black people are cautious about contacting services. More people need to be seen in primary care but is that alone enough of an explanation? Either we need to accept that there is institutional racism and tackle it or some real emphasis needs to be put on finding out why these rates of mental illness are occurring.'

For Mr Heginbotham, the case for an inquiry is clear-cut. What remains to be done is to persuade the secretary of state. 'Why is there not the same level of outrage about black people being admitted to mental health wards as there was about [access to the cancer drug] Herceptin?'

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay